Acute Appendicitis following Laparoscopic Live Donor Nephrectomy.

Acute abdominal pain following laparoscopic live donor nephrectomy (LLDN) might be a diagnostic dilemma, and prompt diagnosis and management is of paramount importance. Herein, we describe a case of acute appendicitis in a 62-year-old kidney donor who presented with acute abdominal pain 16 days following LLDN with features inconsistent with a diagnosis of acute appendicitis. An ultrasound scan suggested strangulated Spigelian hernia unrelated to the operative wound. Exploration of the wound and mini-laparotomy showed no evidence of wound dehiscence or a hernia, but revealed an inflamed appendix wrapped up with omentum. Appendectomy led to complete recovery of the patient. It is imperative to maintain a high index of suspicion for acute appendicitis in this situation to avoid septic complications that might adversely affect the residual renal function and cause negative impact on kidney donation. To the best of our knowledge, this is the first reported case of acute appendicitis following LLDN.

Lifestyle factors associated with glycaemic control and body mass index in older adults with diabetes.

OBJECTIVE: To investigate the relations between lifestyle factors (diet and exercise), glycated haemoglobin (HbA(1c)) and body mass index (BMI) in older adults with diabetes. DESIGN AND SETTING: A community hospital-based cross-sectional study of 150 noninstitutionalized, ambulatory adults (>/=65 y) with diabetes, residing within New Zealand's Kapiti region. SUBJECTS: Patients were recruited from all general practices; two diabetes clinics; local diabetes society and through advertisements in community newspapers. A total of 211 eligible people were identified, but 60 refused to participate and one withdrew. In all, 150 people completed the study (71% participation rate). METHODS: Nutrient intakes were calculated by a food-frequency questionnaire. Physical activity was assessed by interview using a validated questionnaire. Medical history and demographic data were obtained by interview or self-completed questionnaires; height, weight and HbA(1c) were measured. Multivariate models using bootstrapping and stepwise linear regression were used to select factors associated with HbA(1c) and BMI. RESULTS: Each five-unit increase in energy from dietary saturated fat and five-unit increase in BMI were associated with 6% (95% confidence interval=2-10%; P=0.004) and 4% (0.3-7%; P=0.031) increases in HbA(1c), respectively. For females with moderate, compared with low overall activity, there was a 14% (7-20%; P=0.000) reduction in BMI while for males the reduction was only 5% (-1-11%; P=0.116). BMI decreased 5% (2-9%; P=0.004) with each 10-y increase in age, while a five-unit increment in energy from dietary sucrose was associated with a 6% (1-11%; P=0.025) increase in BMI. CONCLUSIONS: Reducing dietary saturated fat and excess body weight may be useful means of improving glycaemic control in older adults with diabetes. Increasing physical activity and reducing energy from dietary sucrose may assist weight control, the former particularly in women.

Selenium and zinc status are suboptimal in a sample of older New Zealand women in a community-based study.

The importance of selenium and zinc in the immune functioning of the aged is widely recognized. Seniors in New Zealand are at particularly high risk of low selenium status because of the low selenium soil environment. The zinc status of the New Zealand elderly has never been assessed. In this cross-sectional study, the biochemical selenium, zinc and lipid levels, physical functional capacity and dietary intakes of 103 randomly selected free-living New Zealand women (mean age +/- SD, 75 +/- 3 y) were assessed. Among nonusers of selenium supplements (n = 80), 80% [95% confidence interval (CI): 70; 88%] had plasma selenium levels (0.85 +/- 0.23 micromol/L) below 1.00 micromol/L [ approximately 10% below mean plasma selenium necessary for full expression of glutathione peroxidase (GPx) activity in New Zealand subjects]. Plasma selenium was strongly correlated with GPx: r = 0.56; P < 0.0001. For nonusers of zinc supplements (n = 88), serum zinc concentrations were 12.4 +/- 1.4 micromol/L, with 12% (95% CI: 6; 21%) having levels below the cut-off value (10.7 micromol/L). Estimated mean daily selenium and zinc intakes were 34 +/- 10 microg and 8.7 +/- 2.0 mg, respectively. Subjects in the highest tertile of a functional capacity index had higher biochemical zinc and selenium values than those in the lowest tertile (P < 0.05). The correlation between plasma selenium and GPx indicates that selenium intake in these women is still insufficient for full expression of GPx activity. Lower serum zinc levels also appear to be prevalent. Because a suboptimal trace element status may be more common among those with a poor physical functioning, promotion of the consumption of nutrient dense foods or supplements to improve selenium and zinc status of elderly women in New Zealand may be beneficial.

Women's readiness to follow milk product consumption recommendations: design and evaluation of a 'stage of change' algorithm.

OBJECTIVE: To investigate readiness to follow milk product consumption recommendations in two random samples of New Zealand women, using an algorithm designed and evaluated to assess the stage of change construct of the Transtheoretical Model. PROTOCOL: Women were classified according to stage of readiness to perform two goal behaviours: consumption of two or four servings of milk products per day. Stage classification, as determined by the algorithm, was evaluated by estimating mean calcium intake in each stage using a validated food frequency questionnaire. This was undertaken in two independent samples of women randomly selected from the electoral rolls of two cities in New Zealand's South Island. RESULTS: Over 60% of women were classified as maintaining an intake of two servings of milk products per day. Of those women not meeting the goal of two servings per day, 73% had no intention of increasing their consumption. Over 80% of women were in the precontemplation stage for consuming four servings of milk products per day. Mean calcium intakes were significantly higher in women classified in action and maintenance stages than in preaction stages of change for both goal behaviours. CONCLUSION: Of those women not currently meeting the recommendation for two servings of milk products per day, most are in precontemplation, a stage characterized by resistance to change. Use of the staging algorithm developed in this study makes possible the classification of women according to their readiness to change, and thus the provision of appropriate stage-tailored advice.

Women's confidence to consume adequate servings of milk products: validation of a summated rating scale.

OBJECTIVE: To design and validate a scale to assess women's confidence to consume adequate servings of milk products. DESIGN: Using the electoral rolls as a sampling frame, two large random population surveys of women aged 25-70 years were conducted. The structure of the self-efficacy scale was explored in the first survey of 500 women, and the component structure was refined and confirmed in an independent sample of 1200 women. RESULTS: The final single component self-efficacy scale consisted of nine items to assess confidence to consume milk products in various situations. Confidence was higher in women who were already consuming adequate servings of milk products than in women who were not yet ready to consume adequate servings of milk products, providing construct validity for the scale. CONCLUSION: The data provide preliminary support for the validity of the self-efficacy scale. The potential usefulness of the scale in interventions designed to improve women's milk product consumption is discussed.

Attaining optimal bone status: lessons from the 1997 National Nutrition Survey.

AIMS: To examine the adequacy of calcium intake in relation to current recommendations, demographic differences in calcium intake and dietary sources in the New Zealand population. METHODS: 24-hour diet recall and qualitative food frequency data from the 1997 New Zealand National Nutrition Survey (NNS97) were used. RESULTS: No age-gender subgroups had median intakes meeting the latest (1998) US recommendations. Women's median intakes failed to meet even the considerably lower 1990 Australian recommendations. 20% of New Zealanders and one in four women had intakes below the UK Estimated Average Requirements for calcium. Intakes below the UK Lower Reference Nutrient Intake (the level at which the risk of deficiency is virtually 100%) were common (15-20%) among women aged 15-18 years, those living in the most deprived areas or Maori. Milk and milk products were the major sources of the nation's calcium intake. CONCLUSION: Although other factors such as genetics, hormonal status, vitamin D status and exercise influence skeletal health, adequate calcium intakes are important in minimizing bone loss. A reduction in the proportion of New Zealanders with inadequate calcium intakes will most readily be achieved if more people meet the milk products Dietary Guideline (minimum of two servings daily). Health professionals can play an important role in raising perceptions of the benefits of adequate calcium intakes, promoting the milk products Dietary Guideline, and emphasising that lower fat diets can include adequate calcium through use of reduced fat milk products.

Perceived benefits and barriers of increased fruit and vegetable consumption: validation of a decisional balance scale.

OBJECTIVE: To develop and validate scales to assess perceived benefits and barriers (decisional balance) for increasing fruit and vegetable consumption. DESIGN: A cross-sectional mail and telephone survey was conducted. SUBJECTS/SETTINGS: A total of 1200 Chinese households were randomly selected from the Singapore residential telephone listings, and 71% responded to the mail survey; 390 males and 406 females participated (mean age = 39.3). MAIN OUTCOME MEASURES: Decisional balance, stage of change, and fruit and vegetable consumption were measured. STATISTICAL ANALYSES PERFORMED: Using a split-half sample approach, developmental sample responses were analyzed by principal-components analysis and validation sample responses by confirmatory factor analysis. Analyses of variance were used to examine stage differences in decisional balance. RESULTS: Principal-components analysis indicated two components representing benefits (or pros) (Cronbach's alpha = 0.86) and barriers (or cons) (alpha 0.79) of change. Confirmatory factor analysis strongly supported the two-component structure (Goodness of Fit Index = 0.97). There was a shift from cons to pros being more important across the stages. The increase in pros across the stages of change (p < 0.0001) corresponded to a medium effect size, and the decrease in cons (p < 0.01) corresponded to a small effect size. IMPLICATIONS: Decisional balance scales may be used to guide interventions to influence fruit and vegetable consumption.

Defining and measuring stages of change for dietary behaviors: readiness to meet fruit, vegetable, and grain guidelines among Chinese Singaporeans.

OBJECTIVE: To assess the ability of 2 algorithms to classify people by stage of change for consuming the recommended servings of grains (cereal foods) and total fruit and vegetables. DESIGN: Assessment of stage involved an objective behavioral measure in the form of a self-administered food frequency questionnaire, followed by a brief telephone interview to assess intentions of subjects to increase intake to meet the recommended servings. Validity of the stage classification was assessed by comparison with three 24-hour dietary recalls. SUBJECTS: One hundred and one Singaporean Chinese subjects (mean age = 38.7; 51% men) were recruited from 716 respondents who had taken part in a survey investigating factors influencing consumption of grains, fruit, and vegetables. STATISTICAL ANALYSES PERFORMED: Differences in mean intake by diet recalls across the stages were investigated using analysis of variance. Sensitivity, specificity, and predictive values of the algorithms were also determined. RESULTS: There were significant increases across the stages in mean intake of grains (men: F(2,48) = 20.30, P < .001; women: F(2,47) = 23.39, P < .0001), and total fruit and vegetables (men: F(2,48) = 30.29, P < .005; women: F(2,47) = 37.29, P < .0001). Based on diet recalls for grains intake, the algorithms classified 89% of subjects having inadequate intakes into the preaction stages, and 75% of those having adequate intakes into the action or maintenance stages. For fruit and vegetables, 93% of subjects having inadequate intakes were classified into the preaction stages, and 76% of those having adequate intakes were classified into the action or maintenance stages. CONCLUSION: Algorithms developed to assess stages of change for food-based rather than nutrient goals, and which include an objective assessment of intake, appear to improve the accuracy of stage classifications.

Self-efficacy and consumption of fruit and vegetables: validation of a summated scale.

PURPOSE: To develop and validate a scale to assess self-efficacy for increasing fruit and vegetable consumption, and to assess the ability of the scale to discriminate individuals at different stages of readiness to change. METHODS: Data were collected using a combination of self-administered mail questionnaires and phone interviews from a sample of 1200 Chinese Singaporeans randomly selected from residential phone listings. Principal-components analysis was conducted with half the sample, and model fit was measured using structural modeling procedures on the other half. Analyses of variance were used to determine whether self-efficacy differed across the stages of change. SETTING: Data were collected as part of a larger study investigating factors influencing consumption of fruit, vegetables, and cereal foods. MEASURES: Fruit and vegetable intake was measured using a validated seven-item food frequency questionnaire. Subjects were assigned to stages using a phone-administered staging algorithm. Self-efficacy items were scored on a five-point Likert scale from very confident to not at all confident. RESULTS: Principal-components analysis revealed a two-factor structure that was highly stable across two split-half samples and gender, and accounted for 57% of the variance in self-efficacy. The two factors demonstrated good internal consistency (Cronbach's alpha = 0.77 and 0.89), with loadings ranging from 0.59 to 0.86 (mean = 0.70). Confirmatory factor analysis demonstrated good model fit (goodness-of-fit index = 0.99), with all parameters significant. Scores on the scale were significantly higher among subjects assigned to maintenance than among those assigned to precontemplation, contemplation, and preparation. CONCLUSIONS: Results of this study provide preliminary evidence for the utility of the scale to guide development and monitoring of community programs and therapeutic interventions.

Changes in dietary intake during a 6-year follow-up of an older population.

OBJECTIVE: To examine prospective changes in food habits and nutrient intakes in a representative New Zealand sample of community dwelling adults aged 70 y and over. DESIGN: Longitudinal study with food intake data collected in 1988/89 and again in 1995/96. In an attempt to distinguish age, time and cohort effects, data were analysed longitudinally, cross-sectionally and time-sequentially. SUBJECTS: The sample for study consisted of all non-institutionalised people aged 70 years and over registered with the Mosgiel Health Centre in 1988. In 1988/89, 678 adults completed a dietary survey (85% of those eligible) and 248 adults participated again in 1995/96 (66% of those eligible). RESULTS: Energy intakes declined longitudinally in men only; however, this decline appeared not to be an aging effect as energy intake was not found to decrease with age cross-sectionally. Percentage of energy from protein increased by 0.7% in women (95% confidence interval 0.2-1.2) in both the longitudinal and time-sequential analysis, suggesting a time effect. The percentage of energy from saturated fat decreased 0.7% (95% confidence interval -1.4 to -0.1) and percentage of energy from polyunsaturated fat increased 0.4% (95% confidence interval 0.0-0.7) in women, and appears to be a time effect. However, the increase in saturated fat and decrease in polyunsaturated fat with advancing age seen cross-sectionally suggests a cohort effect also occurring. In 1995/96, more people were using margarine as a spread and vegetable oils to cook meat. Milk and milk product consumption increased (not significantly), and meat intake decreased significantly by 5 and 4 servings per month in men and women, respectively. There was an increase in the proportion of people who ate breakfast cereal at least once a week, and more women ate brown or wholemeal bread in 1995/96. CONCLUSION: Over the 6 y follow-up period studied, there was no indication of an age effect on nutrient intakes in adults aged 70 y and older; however, the changes occurring over time demonstrate that older adults, particularly women, are making changes towards healthier food choices.

Attention is needed to the high prevalence of vitamin D deficiency in our older population.

The aim of this study was to assess the prevalence of vitamin D deficiency in females residing in one large, aged-care facility in Auckland. Thirty-nine residents, most of whom were able to go outdoors without assistance, were tested for midwinter 25-hydroxyvitamin D, and, of these, 36 were tested again in midsummer. The prevalence of frank hypovitaminosis (<10 microg/L) was found to be 49% in midwinter and 33% in midsummer. The vitamin D status of such at-risk individuals could be normalised either by 15-30 minutes of daily sun exposure or, alternatively, a programme of supplementation.

Applying the transtheoretical model to eating behaviour change: challenges and opportunities.

This review provides a rigorous investigation of the question of whether the transtheoretical model (TTM) (or stages of change model) is applicable to eating behaviour change. The TTM is currently the most popular of a number of stage theories being used to examine health behaviour change. Stage theories specify an ordered set of 'stages of readiness to change' into which people can be classified and identify the factors that can facilitate movement from one stage to the next. If eating behaviour change follows a stage process, then nutritionists could identify the predominant stage or stages in a population and focus resources on those issues most likely to move people to the next stage (e.g. from no intention of changing, to thinking about changing). In addressing this question, the review draws on the defining characteristics of stage theories as clarified by Weinstein et al. (1998), provides an in-depth coverage of methodological considerations, and a detailed summary table of dietary studies applying the TTM. Specific recommendations are made for improving the accuracy of dietary stage classifications. Among the key conclusions are: (1) dietary studies using the TTM have been hampered by a focus on nutritional outcomes such as dietary fat reduction, rather than clearly understood food behaviours (e.g. five servings of fruit and vegetables per day); (2) accurate stage classification systems are possible for food-based goals, but major misclassification problems occur with nutrient-based goals; (3) observation of an association between stage and dietary intake is not sufficient to demonstrate the validity of the model for dietary behaviour; (4) there is a need for valid questionnaires to measure all aspects of the TTM, and more research on the whole model, particularly the 'processes of change', rather than on single constructs such as 'stage' (5) cross-sectional studies generally support the predicted patterns of between-stage differences in decisional balance, self-efficacy, and processes of change; (6) studies which test the key hypothesis that different factors are important in distinguishing different stages are rare, as are prospective studies and stage-matched interventions. Only such studies can conclusively determine whether the TTM is applicable to eating behaviour. Since the ultimate test of the TTM will be the effectiveness of stage-matched dietary interventions, the review ends by exploring the requirements for such studies.

Eating your way to a successful old age, with special reference to older women.

A comprehensive definition of successful ageing would combine the elements of survival (longevity), health (lack of disability), and life satisfaction (happiness). Predictors of longevity include being female, being physically active, not smoking, having good cognitive functioning, higher socio-economic status and greater life satisfaction. Predictors of life satisfaction include being healthy (which is in part influenced by nutrition and physical activity), being socially active, having work satisfaction, having a high happiness rating and enjoying sexual activity. To age successfully is therefore the ultimate challenge. This paper cannot address all variables in the equation to successful ageing, but will focus on the value of food and physical activity in later life.

Validation of a short food frequency questionnaire to assess consumption of cereal foods, fruit and vegetables in Chinese Singaporeans.

OBJECTIVE: To assess the ability of a 16-item food frequency questionnaire (FFQ) to measure consumption of cereal foods, fruit and vegetables in Chinese Singaporeans. DESIGN: Subjects completed the questionnaire twice, at the beginning and end of a six-week period during which they also provided three 24 h diet recalls. Estimates of intake from the questionnaire were compared with those from diet recalls. SUBJECTS: Subjects were recruited from a range of occupational groups through random sampling across divisions in the headquarters of the Singapore Ministry of Health. Of the 81 subjects initially recruited, three failed to complete the diet recalls, one was excluded due to changes in diet, and seven did not return the second questionnaire. RESULTS: Mean difference in food group consumption estimated by the two methods did not differ significantly from zero for fruit (0.00 serving, s.d.=0.54, 95% CI= -0.13, +0.12, P=0.95) or vegetables (-0.05, s.d.=0.29, 95% CI= -0.12, +0.02, P=0.13). For cereal foods, the mean difference was small, but significantly different from zero only in women (-0.32 servings, s.d. = 0.92, 95% CI = -0.59, -0.06, P=0.02). At an individual level, cereal food intake as measured by the FFQ may be 37% below or 59% above the diet recall values; and values for total fruit and vegetables may be half or double the recall values. Among subjects whose intake was classified into the lowest quartiles by diet recalls, 78% and 94% respectively, fell into the lowest two questionnaire quartiles for cereal foods, and total fruit and vegetables. The ability of the questionnaire to predict those having inadequate intake based on recall data was more than 90% for the three food groups. CONCLUSION: The short questionnaire cannot replace the three-day recalls in intake assessment for individuals, but it could be used to screen for low consumers in intervention programmes, to assess mean food group intake in population groups, and to rank individuals into broad categories of food group intake.

Validation of a short food frequency questionnaire for assessment of dietary calcium intake in women.

OBJECTIVE: To assess the ability of a short food frequency questionnaire to measure dietary calcium intake in women. DESIGN: Estimates of calcium intake from the food frequency questionnaire were compared with those from seven-day estimated records in 58 Caucasian women aged 25-49 years in Dunedin, New Zealand. SUBJECTS: Subjects were recruited through poster and newspaper advertising around the central business district of Dunedin, New Zealand. Of 69 subjects initially recruited, nine failed to complete diet records and two were excluded on the basis that their diet record was unlikely to represent habitual intake. RESULTS: Mean dietary calcium intakes were 808.1mg/day from the estimated record and 776.9mg/day from the questionnaire. The mean difference in intake by the two methods (31.1mg, SD = 234.0, 95% CI = -30.4-92.7, p = 0.3) did not differ significantly from zero. The questionnaire classified women consuming less than 800mg calcium per day with 78% specificity. 81% of subjects when classified by the records fell into the same or adjacent quartiles when classified by the questionnaire. Only two subjects were grossly misclassified. CONCLUSIONS: The short food frequency questionnaire could be used to assess mean dietary calcium intake in young to middle aged women. The specificity of the questionnaire is high in identifying women who consume < 800mg calcium/day, therefore it could be used to target interventions for those with intakes below this level.

Control over future health in old age: characteristics of believers and sceptics.

In a cross-sectional study of a total population aged 70 years and over in a rural New Zealand township (sample size 682) we investigated factors which characterize those who felt they had a great deal of control and those who felt they had little or no control over future health. In a significant logistic regression model those with a feeling of a great deal of control over future health had a lower prevalence of chronic obstructive lung disease, higher prevalence of diabetes, took less alcohol, were more likely to be satisfied with bowel function, had a lower protein intake, were more likely to participate in strenuous to moderate activity and were less likely to have features of depression. Different perceptions of control were associated with significant differences in health practices and health status.

Relation of age, exercise, anthropometric measurements, and diet with glucose and insulin levels in a population aged 70 years and over.

A community-based sample of people > or = 70 years from Mosgiel, New Zealand, was investigated to determine the relation of age, diet, exercise, drugs, and anthropometric measurements with glucose and insulin. From an initial sample of 856 subjects on August 1, 1988, 782 (91.4%) completed the questionnaires and physical examination. Glucose was estimated in 726 subjects and insulin in 607 subjects 2 hours after a standardized meal. In the multivariate analysis for women, glucose was related to age and exercise, and insulin was related to glucose levels, triceps skinfold thickness, and waist/hip ratios. In the multivariate analysis for men, none of the variables was related to glucose levels; insulin levels were related to glucose and waist/hip ratio. Impaired glucose tolerance in women was associated with high body mass index, waist/hip ratio, lower exercise levels, and the taking of thiazide drugs or oral steroids. In men, no significant model to identify those with impaired glucose tolerance could be developed. Glucose and insulin levels in women were related to age and external factors, particularly exercise and anthropometric measurements. In men, external factors were less clearly related to glucose and insulin levels, but this lack of association in men may be due to the smaller number of men in the sample, their younger age, and the narrower range of values found in the men.

Validity of a short food frequency questionnaire for estimating nutrient intake in elderly people.

Nutrient intakes estimated using a short self-administered semi-quantitative food frequency questionnaire (FFQ) were compared with results obtained from five 2 d diet records using household measures in a group of fifty-three elderly people (mean age 70 years) in Dunedin, New Zealand in 1989. Mean intakes for most nutrients were less than 5% different between the two methods. Correlations between the nutrient intake values (excluding supplements) from the diet records and those from the FFQ ranged from 0.34 for Zn in women to more than 0.75 for protein, Zn and Ca in men. For most nutrients, at least 70% of the subjects when classified by the food records fell into the same quintile or into the within-one-quintile category when classified by the FFQ. These data indicate that in elderly subjects a simple self-administered semi-quantitative FFQ can provide very similar information (for both group and individual intakes for many nutrients) to that obtained from 10 d of careful diet recording.

Factors associated with constipation in a community based sample of people aged 70 years and over.

STUDY OBJECTIVE: The aim was to determine the prevalence and factors associated with constipation in elderly people. DESIGN: The study was a survey involving administration of a structured questionnaire, an interview, and a dietary assessment. SETTING: The survey was community based and the population studied was drawn from the practice records of all five general practitioners serving a rural township of 13,500 people. PARTICIPANTS: 778 (91.8%) of the 856 people aged 70 years and over registered with the five practitioners took part. MAIN RESULTS: 174 subjects had symptoms of infrequent bowel motions or frequent straining at stool or used laxatives regularly. Of this group, 34 had a bowel motion only every 3 d or less frequently and were considered to have constipation. Analysis of this subgroup showed that constipation was more common in women than men, increased with age, and was associated with the use of constipating drugs. Those whose bowels moved infrequently were a more frail group who were less physically active. Low intakes of dietary fibre, fruit, vegetables, bread and cereals, or fluid were not associated with an increased occurrence of constipation. There were 151 subjects who felt they were moderately constipated, but who had a bowel motion at least every 2 d. These people were more likely than the rest of the sample to use laxatives (55.6%), were more likely to take food for their bowels, to take hynoptics, and to regard their health as poor. CONCLUSIONS: About one third of people aged 70 years and over have some bowel problem such as infrequency, straining at stool, or frequent laxative use. Most modify their diet accordingly but laxative use remains high.